Provider Demographics
NPI:1245510320
Name:BURNS, STACEY R (PA)
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:R
Last Name:BURNS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:STACEY
Other - Middle Name:R
Other - Last Name:DWIRE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1000 ASYLUM AVE
Mailing Address - Street 2:SUITE 2109A
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06105-1770
Mailing Address - Country:US
Mailing Address - Phone:860-714-6581
Mailing Address - Fax:860-714-8311
Practice Address - Street 1:114 WOODLAND ST
Practice Address - Street 2:SURGERY
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06105-1208
Practice Address - Country:US
Practice Address - Phone:860-714-4694
Practice Address - Fax:860-714-8096
Is Sole Proprietor?:No
Enumeration Date:2011-08-22
Last Update Date:2016-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT23363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical